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Previous research demonstrated that physical health-related quality of life (HRQOL) improves after liver transplantation, but improvements in mental HRQOL are less dramatic. The aim of this study was to test the effects of physical HRQOL, time post-transplant, and gender on pre- to post-transplant change in anxiety and depression. Longitudinal HRQOL data were prospectively collected at specific times before and after liver transplantation using the SF-36(R) Health Survey (SF-36), Center for Epidemiologic Studies Depression Scale (CES-D), and Beck Anxiety Inventory (BAI). Within-subject change scores were computed to represent the longest follow-up interval for each patient. Multiple regression was used to test the effects of baseline score, time post-transplant, gender, and SF-36 physical component summary scores (PCS) on change in BAI and CES-D scores. About 107 patients (74% male, age=54+/-8 years) were included in the analysis. Time post-transplant ranged 1 to 39 months (mean=9+/-8). Improvement in symptoms of anxiety and depression was greatest in those patients with the most severe pre-transplant symptoms. Significant improvement in symptoms of depression occurred after liver transplant, but the magnitude of improvement was smaller with time suggesting possible relapse of symptoms. Better post-transplant physical HRQOL was associated with a greater reduction in symptoms of anxiety and depression after liver transplantation. This demonstrates clear improvements in post-transplant mental HRQOL and the significant relationships between physical and mental HRQOL. [ABSTRACT FROM AUTHOR]

The purpose of this study was to assess regional variability in access to pediatric liver transplantation. The study population included all pediatric patients (age less than 18 years) listed for liver transplantation in the United Network for Organ Sharing (UNOS) database between 1988 and 2004. The effect of region on waiting list survival, the proportion of patients transplanted, and the proportion of patients remaining on the list was determined using Kaplan-Meier and Cox proportional hazard methods. The proportion of technical variant grafts used was compared between regions using chi-square analysis. Kaplan-Meier analyses showed significant effects of region on survival on the waiting list, transplantation, and remaining on the list (all log-rank P < 0.001). Cox proportional hazard models demonstrated that region, urgency status, and listing period exerted independent effects on survival on the waiting list, transplantation, and remaining on the list (all model P < 0.01). Regional variation existed with regard to donor type (P < 0.001). Similar to adults, pediatric survival on the waiting list, the proportion of patients transplanted, and the proportion of patients remaining on the waiting list vary considerably within the 11 U.S. regions. Organ procurement organization specific effects and regional differences in utilization of deceased donor split and living donor organs may contribute to this variability. [Copyright &y& Elsevier]

Bromfenac sodium (Duract) is a phenylacetic acid-derived nonsteroidal anti-inflammatory agent introduced in the United States in 1997 and withdrawn in 1998. We describe the first case of fulminant hepatic failure associated with this agent treated successfully with liver transplantation. Similarities to hepatotoxicity with related agents is discussed. [ABSTRACT FROM AUTHOR]

Determines individual outcome of treatment strategies on hepatocellular carcinoma (HCC) in Nashville, Tennessee. Types of treatment strategies for HCC; Survival rates of patients according to type of treatment strategy; Differences in survival rate of patients at different stages of HCC; Predisposing factors and complications of HCC.

Radical resection (wedge resection of the gallbladder bed and dissection of the hepatoduodenal ligament, portal, and celiac lymph nodes) has been reported to improve survival from pathologic T[sub 2] gallbladder carcinoma (pT[sub 2] GBCa; invasion through the muscularis without perforation of the serosa). We report our experience and the outcome of patients with pT[sub 2] GBCa. Between 1989 and 2000 at Vanderbilt University Medical Center ten patients were found to have pT[sub 2] disease after cholecystectomy. The patients had an average age of 64 +/- 13 years and underwent either radical resection (n = 5) or no further surgical therapy (n = 5). Of the patients who underwent cholecystectomy only, one (20%) is still alive at 27 months and four (80%) died of recurrent GBCa between 6.5 and 21 months. For the patients who underwent radical resection all five are alive at 15 to 83 months with no recurrence. The proportion of patients surviving pT[sub 2] GBCa after radical resection was significantly greater than with cholecystectomy alone (P < 0.05). The difference in length of survival between the two groups was also significant (P < 0.05). Morbidity after radical resection was low (pancreatic leak in one patient), and there were no operative mortalities. Radical resection significantly improved survival over cholecystectomy alone for patients with pT[sub 2] GBCa. The procedure has low morbidity and mortality rates. Therefore a radical resection operation is indicated for patients with pT[sub 2] GBCa. [ABSTRACT FROM AUTHOR]

Over the past decade, splenic preservation has become a well-reported and accepted principle in trauma management. The reasons for splenic preservation may have influenced nontraumatic surgical management as well. To investigate the changing incidence and indications for splenectomy, we conducted a 10-year review of all splenectomies at our institution. During this time, between January 1, 1986, and December 31, 1995, 896 patients underwent splenectomy. Hospital charts and records were examined to determine the etiology and incidence of splenectomy. Indications were classified as: 1) trauma, i.e., performed for blunt or penetrating injury; 2) hematologic malignancy, i.e., therapy or staging of underlying leukemia, Hodgkin's lymphoma, or non-Hodgkin's lymphoma; 3) cytopenia, i.e., treatment of thrombocytopenia, anemia, or leukopenia; 4) iatrogenic, i.e., injury during another procedure; 5) incidental, i.e., required for adjacent organ resection; 6) portal hypertension, i.e., left-sided portal hypertension or during shunting procedure; 7) diagnostic, i.e., uncertainty excluding hematologic malignancy; or 8) other, i.e., miscellaneous indications. Trauma accounted for 41.5 per cent of all splenectomies during this time period, hematologic malignancy 15.4 per cent, cytopenia 15.6 per cent, incidental 12.3 per cent, iatrogenic 8.1 per cent, portal hypertension 2.3 per cent, diagnostic 2.0 per cent, and other 2.7 per cent. Comparing the first and second 5-year time periods, the following increases/decreases in average annual incidence were noted: splenectomy for all indications, -36.9 per cent; trauma, -32.9 per cent; hematologic malignancy, -51.4 per cent; cytopenia, 35.1 per cent; incidental, -35.9 per cent; iatrogenic, -30.2 per cent; diagnostic, +4.9 per cent, and other, -57 per cent. Traumatic injury to the spleen remains the most common indication for splenectomy, but the incidence has decreased dramatically over the past 10 years. Splenectomies for treatment ... [ABSTRACT FROM AUTHOR]

Background: Exploration of urban-rural (UR) and regional differences is critical to developing effective healthcare delivery systems. Choledocholithiasis (CDL) remains a common problem with a range of therapeutic options and potentially severe complications. This study evaluated UR and regional differences of CDL presentation and treatment. We hypothesized that UR status contributes to differences in treatment of CDL., Methods: This study examined patients from the 2007 Healthcare Cost and Utilization Project dataset. Inpatient discharges and interventions for CDL patients were identified. UR and regional designations were determined from National Center for Health Statistics guidelines. Patients with pancreatitis or cholangitis were designated as complicated CDL (cCDL) patients. Interventions for CDL were classified as endoscopic, surgical, or percutaneous. Complex-sample proportion analyses were performed., Results: A total of 111,021 patients with CDL were identified; 81% of these patients lived in urban areas compared with 19% in rural areas; 61% had uncomplicated choledocholithiasis (uCDL) and 39% had cCDL. The overall distribution of uCDL and cCDL did not differ by UR status or region. A higher proportion of rural patients did not receive an intervention 45.1% (95%CI 41.8%-48.4%) versus urban patients 30.5% (28.8%-32.2%), P < 0.05. Interventions for urban patients were more likely endoscopic 87.7% (86.8%-88.6%) compared with rural 82.0% (79.3%-84.7%), P < 0.05. Rural patients were more likely to undergo surgery 10.5% (8.6%-12.4%) than urban patients 4.9% (4.4%-5.4%), P < 0.05. Regional variations did not impact the type of intervention received., Conclusion: Rural patients received CDL interventions less often and had a higher proportion of surgical interventions regardless of severity of presentation., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Health utility instruments assess patients' valuation of specific health states, which can be converted to quality-adjusted life years for cost-utility analysis. Data from the EQ-5D, a generic health-related quality of life questionnaire from EuroQoL, can be reported as 5 health status scores or as a single health preference weight (HPW). US population-based HPWs were published by Shaw and colleagues in 2005 (Med Care 2005;43:203-220). Our aim was to test the validity of US EQ-5D HPWs and health status scores in liver transplant patients. EQ-5D scores were converted to HPWs with Shaw et al.'s model. Data were stratified by measurement period: pretransplant period, early posttransplant period (< or =12 months), intermediate posttransplant period (13-36 months), and late posttransplant period (>36 months). EQ-5D scores were compared to specific, hypothesized Short Form 36 Health Survey, Center for Epidemiologic Studies Depression Scale, and Beck Anxiety Inventory scores that were identified a priori on the basis of construct similarity. Criterion-related and construct validity were tested with nonparametric methods. Two hundred eighty-five adults participated (113 in the pretransplant period, 60 in the early posttransplant period, 47 in the intermediate posttransplant period, and 65 in the late posttransplant period), and follow-up averaged 36 +/- 36 months. Eighty-one percent of the hypothesized relationships between EQ-5D and gold-standard scales were strong (r > or = |0.5|, P < 0.001), and the remainder were moderate (r > |0.3|, P < 0.001). Differences between pretransplant and posttransplant EQ-5D HPWs were statistically significant. In conclusion, EQ-5D dimensions and the health utility index generated from Shaw's US population preference weights demonstrated criterion-related and construct validity in liver transplant patients. It is a valid instrument for cost-utility analysis in this setting., (Copyright 2008 AASLD.)

Objective: To examine the impact of the Model for End-stage Liver Disease (MELD) on waiting list mortality., Design: Interrupted time series with a nominal inception point of the intervention on February 27, 2002., Setting: United Network for Organ Sharing Standard Transplant Analysis and Research file data from March 1, 1999, to July 30, 2004., Participants: All adult candidates on the waiting list for liver transplantation in the United States during the study period., Intervention: Implementation of the MELD policy., Main Outcome Measures: Waiting list mortality, waiting time to transplantation, number of new registrants, and posttransplantation survival., Results: Although no preintervention trend was identified, the policy change was associated with an immediate effect of increasing waiting list mortality by 2.2 deaths per 1000 registrants per month (from approximately 11 to 13 deaths per 1000 registrants per month; 95% confidence interval [CI], 1.1 to 3.4; P = .001) followed by a postintervention decline in waiting list mortality over time (-0.09 death per 1000 registrants per month; 95% CI, -0.16 to -0.03; P <.001). An immediate effect of decreased waiting time was also noted (from approximately 294 to 250 days; -44.4 days; 95% CI, -77.1 to -11.7 days; P <.001), which reached a new, lower postintervention steady state. The intervention had no effect on the number of new registrants listed per month or on 3- and 6-month posttransplantation survival., Conclusion: After an initial increase in waiting list mortality, the implementation of the MELD-based allocation policy was associated with an overall decline in waiting list mortality and time to transplantation.

Background: We sought to determine if disparities in survival and health-related quality of life (HRQOL) occurred after solid organ transplantation at our institution., Methods: Data were extracted from a database including information regarding transplants that took place from 1990 to 2002. The HRQOL was assessed in patients by using the Karnofsky functional performance (FP) index and the Medical Outcomes Study Short Form 36 (SF-36) questionnaire., Results: Data were collected on recipients of liver (n = 413), heart (n = 299), kidney (n = 892), and lung (n = 156). Blacks represented a minority of recipients: liver 7%, heart 8%, kidney 23%, and lung 6%. There were no statistically significant differences in patient survival between blacks and whites. Graft survival differed in kidney only with a 5-year survival: 72% for blacks versus 79% for whites (P <0.001). The FP and HRQOL improved (P <0.05) after transplantation in both groups. There were no differences on measures of the FP or HRQOL., Conclusions: Blacks had comparable survival and improvement in FP and HRQOL in comparison with whites.

Background: Some previous studies suggested that transplantation performed in Department of Veterans Affairs (VA) patients was associated with a higher rate of complications and poorer outcomes. We examined more than a decade of experience with solid organ transplantation at a single center and compared VA patients with nonveteran patients to assess long-term patient and graft survival and health-related quality of life (HRQOL)., Methods: Demographic, clinical, and survival data were extracted from a database that included all transplants from January 1990 through December 2002 at Vanderbilt University Medical Center (non-VA) and the Nashville VA Medical Center (VA). The HRQOL was assessed in a subset of patients using the Karnofsky functional performance (FP) index and the Short-Form-36 self-report questionnaire. Data were analyzed by Kaplan-Meier survival and analysis of variance methods., Results: One thousand eight hundred nine adult patients receiving solid organ transplants (1,896 grafts) between 1990 and 2002 were reviewed: 380 VA patients (141 liver, 54 heart, 183 kidney, 2 lung) and 1429 non-VA patients (280 liver, 246 heart, 749 kidney, 154 lung). Mean follow-up time was 46 +/- 1 months. Five-year graft survival for VA and non-VA patients, respectively, was liver 65% +/- 5% versus 69% +/- 3% (P = 0.97); heart 73% +/- 8% versus 73% +/- 3% (P = 0.67); and kidney 76% +/- 5% versus 77% +/- 2% (P = 0.84). Five-year patient survival was liver 75% +/- 5% versus 78% +/- 3% (P = 0.94); heart 73% +/- 8% versus 74% +/- 3% (P = 0.75); and kidney 84% +/- 4% versus 87% +/- 2% (P = 0.21) for VA and non-VA, respectively. In the first 3 years after transplant, the FP scores for VA versus non-VA patients were 85 +/- 2 versus 87 +/- 1 (P = 0.50). The SF-36 mental component scales were 47 +/- 3 versus 49 +/- 1 (P = 0.39); and the SF-36 physical component scales were 37 +/- 2 versus 38 +/- 1 (P = 0.59), respectively. Longer-term (through year 7) HRQOL scores for VA versus non-VA patients were FP 85 +/- 1 versus 88 +/- 1 (P = 0.17); mental component scales 47 +/- 2 versus 49 +/- 1 (P = 0.29); and physical component scales 35 +/- 2 versus 39 +/- 1 (P = 0.05), respectively., Conclusions: The veteran patients have similar graft and patient survival as the nonveteran patients. Overall quality of life is similar between veterans and nonveterans during the first three years after transplantation. A trend toward a later decline in the veterans' perception of their physical functioning may stem from the increased prevalence of hepatitis C virus among VA liver transplant recipients, a known factor reducing late HRQOL.